The Top Ways Palcohol Abuse Could Present to the Emergency Department

The world may not need Palcahol – powdered alcohol – but it’s coming soon. Here’s a rundown of how it could present in your emergency department.

It’s a typical night in the ED when the paramedics bring you an unconscious 15 year old. They tell you his parents came home and found him down on the ground and immediately called 911. The teenager is minimally responsive with sluggish pupils and respiratory depression. The paramedics are actively bagging him as he is brought into the resuscitation room. As he is moved over to the gurney, a bag full of white powder falls out of his pockets. You don’t see any track marks but have the nurse draw up naloxone as you suspect this is another unfortunate opioid overdose. An IV is placed, labs are sent, and naloxone is pushed and…nothing. Somewhat surprised, you administer a larger dose. After administering 10 mg of naloxone without any response, you bite the bullet and intubate him. His labs come back and the urine drug screen is negative, however, his ethanol concentration is 400 mg/dl. You inform his parents, and they deny that there is any alcohol in the house. You arrange for a bed in the ICU but are still somewhat perplexed by the white powder. As you are signing your last chart, your relief shows up and you relay the events of the night. Your colleague says, “Powder, huh? I bet it was that Palcohol that is all over the news!”

Palcohol is a brand of powdered alcohol that will be released in the United States this summer. Powdered alcohols use carbohydrate powders that trap alcohol to keep it in a dry form. The powder is easily dissolved in water or another liquid to form an alcoholic beverage [1]. The powder packets are meant to be mixed in six ounces of water, resulting in a drink with the same alcoholic content as a standard mixed drink [2]. Palcohol will come in five flavors: vodka, rum, cosmopolitan, lemon drop, and margarita.

Editor’s Note: K2 Puts Palcohol in PerspectiveA key factor in guessing Palcohol’s abuse potential is how people will be able to buy it. The website notes that no US distributors are sought; suggesting people will be able to buy it online.This spring, New York, Alabama and Mississippi health departments issued alerts about startling rises in synthetic cannabis usage, which has spilled into EDs and ICUs – and morgues. Arizona, Florida, New Jersey and Texas also saw increased usage – hitting close to 200 visits a day in April.

Known as K2, Spice, or other names, these substances are often more much more potent than marijuana, and mixed with adulterants and hallucinogens. The ED presentation this spring has varied from agitation to somnolence, palpitations to GI symptoms to seizures.

K2 and its like are illegal in New York, and many other places, but still find their way into the hands of teenagers and young adults. I’ve seen K2 on sale in NYC bodegas – it’s on display as a potpourri scent, even though the labeling suggests its real purpose.

So as we debate Palcohol’s impact on the ED, I’m wondering: If packets of K2 are leading to so many pediatric ED visits, despite its illegality, how will packets of legal Palcohol stay out of the hands of teens?-Nicholas Genes, MD, PhD

Palcohol has traveled a winding path through the US regulatory system. The FDA issued a statement last summer, saying they have no concerns about the ingredients and thus, no legal basis to block sales. It then fell to the Alcohol and Tobacco Tax and Trade Bureau for approval and product labeling. They did so in 2014, but then quickly withdrew their approval, before re-issuing approval in March of this year. In the meantime, several states have either passed or proposed legislation to ban the product [3]. NY Senator Chuck Schumer has called for legislation to ban the substance at a federal level, but so far this push hasn’t yielded results in Congress.

While similar products are already available in Europe [4], very little is known about them. Palcohol’s website argues that their product fills a unique need and gives examples of instances where it would be superior to liquid alcohol. For instance, it is cumbersome to carry alcohol on a long hike so it might be easier to just carry a powder and then reconstitute it later. The site also claims that airlines could save millions in fuel costs by carrying powdered alcohol instead of heavier liquid alcohol (but since passengers would still need the airline to provide water to drink it down, that claim seems questionable). The company also plans to produce an industrial version – potentially shipping and storing alcohol as a powder could reduce costs and space constraints, compared to shipping and storing a liquid.

The product has gained a lot of attention from the media due to fears of misuse and abuse [5]. As it is sold in small packets, there are concerns that someone could easily sneak it into a public event or purposely adulterate a drink with it. These same concerns appeared in Germany after the release of a different brand of powdered alcohol [6]. Much of the media’s attention revolves around concerns of misuse by underage or novice drinkers. This includes a concern that the product will be available to teenagers and young adults unable to purchase alcohol at liquor stores or bars. The younger consumer may also be drawn to flavors such as cosmopolitan or margarita. In Germany, the powdered alcohol Subyou allegedly had slogans such as “taste for not much dough” and “gets a good buzz going” which were likely intended to appeal to a younger market [6].

As this is a new product and people will not be familiar with it, they may inadvertently misuse it. For instance, it is possible that people will not understand the alcohol content of a single packet and mix multiple packets together resulting in a higher degree of intoxication than expected. An analogous situation was seen with Four Loko and other caffeinated or flavored alcoholic beverages [7] – people were quickly consuming large volumes of these beverages; the caffeine kept them from realizing how intoxicated they were. This effect led to multiple cases of altered mental status, respiratory depression and even a few deaths [8]. While the Federal Trade Commission required the manufacturer to adjust the labels of products such as Four Loko to better disclose the alcoholic content of their product, some research concludes that this is not adequate to prevent hazardous consumption by underage drinkers [9].

Even with the labeling change, people will inevitably find new ways to abuse Palcohol. Since it is sold as a powder, there are concerns that it could be snorted like heroin or cocaine. This might seem odd – even painful but people have been quite creative in finding new routes to absorb alcohol, even opting for ocular and rectal avenues.

For their part, Palcohol’s leadership has started an aggressive campaign to address these concerns. In fact, the main page of their website is dedicated to the argument that powdered alcohol is safer than liquid alcohol. Mark Phillips, the inventor of Palcohol, points out that if their product is consumed properly, each packet has the same amount of alcohol as a standard drink. In addition, he believes smuggling powdered alcohol into a public venue is no easier than liquid alcohol. Phillips also attempts to debunk fears about snorting the powder, citing that it will not get you drunk faster, you would have to snort a lot of it to become intoxicated, and it would be very painful to do so.

What Phillips doesn’t say is his website at one time described Palcohol as a concealable alternative to more expensive drinks at public events [10]. Phillips also undermines some of his credibility when he makes claims, that a ban of his product would be fiscally irresponsible.

Even though the powdered alcohol called Subyou was introduced in Germany a decade ago, we just don’t have much experience with the substance yet.10 Very little appears in mainstream journalism and nothing about powdered alcohol is published in the medical literature. Much of the concern that has already been raised is speculative in nature. Likely, there will be instances of powdered alcohol being misused or abused. How often this will occur, especially in comparison to the daily misuse and abuse of liquid alcohol, is unknown. How this will affect teenage and underage drinking and substance abuse is also unknown.

Whenever a potentially abusable new substance is introduced, there’s a period of experimentation and accidents – so it’s likely we’ll see at least a few cases in EDs this summer. While I’m not sure Palcohol or powdered alcohols really fill a needed niche or provide much of a benefit compared to liquid alcohol, I’m also not sure if the entire public backlash is warranted. At least, not yet.

I think the purpose of the case is familiarizing the reader with the concept of powder alcohol. Is it possible for for someone to get drunk with powder alcohol and ends up getting intubated because we don’t know what’s really underlying cause is, absolutely yes. People do stupid thing. Last time I checked hydromophone was supposed to make you high. Not for injection into penis ! This was a case recently I came across.

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